16
`
`that .propranolol in a single dose of 120 mg caused normal
`people to feel significantly more troubled than when on place(cid:173)
`bo and that these feelings occurred in !the absence of sedation.
`Perhaps alteration of bodily sensa.tion-s may be perceived
`as unpleasant by those who do not complain of somatic
`anxiety. The therapeutic indications for propranolol in patho(cid:173)
`logical anxiety seem to be confined to patients who do not
`complain of anxiety even though .their somatic symptoms are
`clearly due to anxiety. Symptoms caused by tachycardia and
`tremor, both of which are significantly lessened by be·ta(cid:173)
`adrenoceptor blockade in anxious patient-s (Turner et al.,
`1965; Marsden et al., 1968; Tyrer and Lader, 1973), are
`especially likely to be helped. In such patients the removal
`of .the symptom is enough to bring considerable clinical relief.
`This suppotts the view that bodily symptoms may be more
`fundamental in morbid emotion 'than
`is usually
`thoue;ht
`(Tyrer, 1973), and is consistent with ithe long-standing clini(cid:173)
`cal impression that patients wi~h somatic complaints are best
`tteated by somatic therapy (Misch, 1935).
`The results of our ~udy are also consistent with previous
`reports of the effectiveness of beta-receptor blockade in other
`oonditions. It could be argued tl:hat the primary complain't in
`"hyperoynamic beta-adrcnergic circulatory state" (Frohlich
`et al., 1966), "nervous hearc complaint" (Norocnfelt et al.,
`1968), "hyperventilation syndrome" (Suzman, 1968), and
`"vasoregu!atory asithenia" (Holmgren et al., 1957) is ithat of
`anxiety presenting in the guise of somatic malfunction. In all
`these conditions beta-receptor blockade is beneficial (Mars(cid:173)
`den, 1971). If the spectrum of somatic anxiety is extended
`to include such functional disorders the -type of patient suit(cid:173)
`able for .t:rcatmcn<t with beta-blocking agcms is bet•ter defined.
`It remains to be seen whether <there are differences in res(cid:173)
`ponse between individual beta-blocking agent·S but from our
`knowledge of their clinical effect>S in other condi,tions this
`seems unlikely, provided <they are given in equipotent dosage
`(Thadani et al., 1973). The clinical presentation of anxiety
`is so varied and the pharmacological differences between the
`beta-blocking drugs so small by comparison that i<t is the
`
`BRITISH MEDICAL JOURNAL
`
`6 APRIL 1974
`
`selection of the right patient for treatment rather than choice
`of drug which is likely to be critical for success.
`
`We are grateful to Dr. P. Bayliss of I.C.I. Pharmaceuticals Divi(cid:173)
`sion for supplying the capsules of propranolol, diazepam, and place(cid:173)
`bo, and to Vivien Maclean for co-ordinating their allocation. This
`work was supported by the Medical Research Council.
`Requests for reprints should be sent to Dr. Tyrer.
`
`References
`Bonn, J. A., Turner, P., and Hicks, D. C. (1972). Lancer, 1, 814.
`Conway, M . ( 1971). Practitioner, 206, 795.
`Frohlich, E. D., Dunstan, H.P., and Page, I. H. (1966). Archives of Internal
`M edicine, 117, 614.
`Granville-Grossman, K. L ., and Turner, P. (1966). Lancer, 1, 788.
`Hamilton, M . ( 1959). British Journal of Mtdical Psychology, 32, 50.
`Holmgren, A., ti al. (1957). Acta Medica S candinavica, !SS, 437.
`Lader, M . H., and Marks, I. M. ( 1971). Clinical Anxiety, p. 99. London,
`Heinemann.
`Lader, M. H., and Tyrer, P . J. ( 1972). British Journal of Pharmacology, 4S,
`557.
`McMillin, W. P. (1973). Lancet, 1, 1193.
`Marsden, C. D., Gimlette, T. M. D., McAllister, R. G., Owen, D. A. L.,
`and Miller, T. N. ( 1968). Acta Endocrinologica (Kt!Jenhavn), S1, 353.
`Marsden, C. W. ( 1971). Postgraduate Modica/Journal, Suppl. 47, 100.
`Misch, W. ( 1935).Journal of Mental Science, 81, 389.
`Nordenfelt, I., Persson, S., and Redfors, A. (1968). Acra Medica Scandi(cid:173)
`navica, 184, 465.
`Ramsay, I., Greer, S., and Bagley, C. (1973). British Journal of Psychiatry,
`122, 555.
`Robe.rtS, J. M ., and Hamilton, M . ( 1958). Journal of Mental Science, 104,
`1052.
`Shand, 0 . G., Nuckolls, E. M., and Oat~, J. A. ( 1970). Clinical Pharma(cid:173)
`coloxy and Therapeutics, 11, 112.
`Siegel, S. ( 1956). Non-parametric S tatistics for the Behavioral Sciences,
`p. 229. New York, McGraw-Hill.
`Suzman, M. M. ( 1968). Annals of Internal M edicine, 68, 1194.
`Thadani, U., er al. (1973). British Medical Journal, I, 138.
`Turner, P., Granville- Grossman, K. L ., and Smart, J. V. (1965). Lancer, 2,
`1316.
`Tyrer, P. J. (1973). Lancer, I, 915.
`Tyrer, P. ]., and Lader, M. H. (1973). Clinical Pharmacology and Thera(cid:173)
`peutics, 14, 418.
`Van der Kleijn, E. (1971 ). Annals ofrhe New York Academy of Sciences, 179,
`115.
`Wheatley, D. (1969). Brirish Journal of Psychiatry, 115, 1411.
`Winer, B. J. ( 1962). Srarisrical Principles in Experimental Design. New York,
`McGraw-Hill.
`
`Long-term Chelation Therapy in Thalassaemia Major:
`Effect on Liver Iron Concentration, Liver Histology,
`and Clinical Progress
`
`MICHAEL BARRY, DAVID M. FLYNN, ELIZABETH A. LETSKY, R. A. RISDON
`
`British Medical Journal, 1974, 2, 16-20
`
`Summary
`A prospective trial of continuous chelation therapy in chil(cid:173)
`dren with homozygous tbalassaemia on a high transfusion
`
`Department or Medicine, Royal Free Hospital, London WCtX SLF
`MICHAEL BARRY, M.n., M.R.c.P., Senior Medical Registrar
`Hoapital for Sick Children, Great Ormond Street, London W.C.1
`DAVID M. FLYNN, M.D., M.R.C.P., H<~no~ Consultant Physician
`(Present appointment: Consultant Paecbatttaan, Royal Free Hospital,
`:London.)
`Department or Haematology, Inadtute of Child Health, London W.C.1
`ELIZABETH A. LETSKY, M.B., M.R.C.PATH., Lecturer in Haematology
`Department or Morbid Anatomy, lnsdtute or Child Health, London
`w.c.1
`R. A. RISDON, M..n ., M.R.C.PATH., Senior Lecturer in Morbid Anatomy
`
`regimen was started in April 1966. Tbe effect of treabnent
`on iron concentration in the liver and on hepatic histology was
`examined in 49 biopsy specimens obtained from nine chela(cid:173)
`tor-treated patients and nine control patients between April
`1966 and April 1973.
`Chelation therapy was associated with a significant reduc(cid:173)
`tion in liver iron concentration, and by the end of the trial
`the values for the two groups showed no overlap. A similar
`difference was seen in tbe amount of hepatic fibrosis, which
`showed little or no change in the chelator-treated patients
`but was progressive in the controls.
`No major clinical differences were seen, probably because
`both groups included several older children who were heavily
`loaded with iron at the start of the trial Among the younger
`patients, however, puberty was delayed in four of five con(cid:173)
`trols but in only one of four chelator-treated children. Pre(cid:173)
`pubertal growth rate was significantly greater in the chelator(cid:173)
`treated patients than in the controls.
`
`
`1 of 5
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1018
`
`

`

`BRITISH MEDICAL JOURNAL
`
`6 APRIL 1974
`
`Introduction
`
`Iron overload has been recognized as a prominent feature of
`thalassaemia since Whipple and Bradford (1936) emphasized
`the characteristic pattern of heavy visceral iron deposition,
`which 1they likened to that of adult haemochromatosis. At
`that time most patients with dlalassaemia died in childhood
`from anaemia and cardiac failure, and the tissue damage
`typical of haemochromatosis was not seen. As che use of
`blood transfusions increased, however, survival was pro(cid:173)
`longed into adolescence and early adult life and haemochro(cid:173)
`matosis came <o be regarded as a major cause of death
`(Frumin, et al., 1952; Howell and Wyatt, 1953; Ellis, et al.,
`1954). The relative importance of iron excess and tissue
`hypoxia in ithe genesis of ill-heal-th and organ damage re(cid:173)
`mained controversial, but the long-term outcome in children
`maintained on a high <transfusion regimen suggests that iron
`overload is the major factor limiting life (Wolman, 1964;
`Wolman and Omolani, 1969).
`The need ito minimize or prevent iron accumulation in
`thalassaemia is now generally acknowledged and much inter(cid:173)
`est has attached to the use of iron-chelating agents in treat(cid:173)
`ment. Two chelating agents, dcsfcrrioxamine and diethylene(cid:173)
`trimine pema-acctate, have held the field for the past decade
`(Smith, 1962; Smith, 1964). Though urinary iron losses of
`10-50 mg/day can be achieved with eiither compound direot
`information about the effeot of long~term chelation therapy
`on irotal iron-load is lacking and it is not known whether such
`treatment is beneficial. A long-term uial of continuous chela(cid:173)
`tion 1therapy in thalassacm.ic children on a high transfusion
`regimen was sta.l!ted at the Hospital for Sick Children in
`1966. This paper reports the changes in liver iron concentra(cid:173)
`tion and histology and the clinical progress in the chelator(cid:173)
`treated and prospectively-selected control patients between
`1966 and 1973.
`
`Patients and Methods
`The itrial was started in April 1966, when 10 patients with
`,B-thalassaemia major began continuous chelation
`therapy
`and were allocated ito <the treatment group. Ten patients who
`were to receive no chelators were selected oo controls. Selec(cid:173)
`tion was performed so as to obtain two groups matched as
`closely as possible for sex, age, transfused iron load, and
`splenec1omy status. One patient in each group failed to c?m(cid:173)
`plete 1the •trial. The details of che remaining 18 are summarized
`in ithe ta·ble. The mean age of <the comrols was slightly greater
`than <that of the chelator-itreated patients and <the average
`amount of blood received per patient was also higher in the
`control group. These differences, which reflected <the inclus(cid:173)
`ion of <hree younger, less heavily transfused patienits in the
`treated group, remained unchanged <throughout
`the study
`and were not statistically .significant.
`Each patient attended the haemoglobinopathy clinic of the
`Hospital for Sick Children at intervals of 2-4 weeks and w~s
`transfused every 4-8 weeks so as to keep me haemoglobm
`concentration between 8·0 and 15·0 g/ 100 ml. The amount
`of blood given at each ttansfusion was recorded. The chel~or­
`treated patients received desferrioxamine mcsylate 0·5 g m 2
`ml water by intramuscular injection on 6 ?ays each . w~k,
`given at home by the district n~rsc, and d1.ethylenemanune
`penta-acetate 2 g intravenously with each umt of bloo_d. The
`use of the latter drug eventually had to be stopped m four
`children owing to adverse reaotions, dcsfcrri~xamine ~g
`given instead. The mean duration of chelation therapy 10
`those patients receiving this treatment was 5·8 years (range
`5·2-6·3 years).
`.
`The fint liver biopsies were performed m 15 of the 18
`patients at the Sta.I!! of the trial in 19?6· Bio~sy was first p~r­
`f rmcd in one patient in 1967 and m one 10 1969. Interun
`b~opsies were performed in many patients in 1967 and 1969.
`
`17
`
`Final liver biopsies were performed in 17 patients between
`June 1971 and August 1972, and a specimen of liver obtained
`from the remaining patient at necropsy in April 1973. Biopsy
`was not performed in one patient in the control group until
`the end of the trial. Liver tissue for biopsy was obitained by
`percutaneous needle puncture under general anaesthesia ex(cid:173)
`cept for wedge specimens taken from two patients at the time
`of splencctomy in 1972. The aims and conduct of the trial
`were approved by the ethics commitite of die hospital and the
`informed consent of the parents was obtained both to in(cid:173)
`clusion in the trial and <o every liver biopsy.
`Assessment of Iron Stores.-Liver concentration was deter(cid:173)
`mined by the method of Barry and Sherlock (1971). Fresh
`specimens were oven-dried and weighed cto the nearesit O·Ol
`mg. Dulpicate biopsy specimens were itaken in 10 cases; the
`standard error for a single specimen corresponded to a co(cid:173)
`efficient of variation of 6·6%. Paraffin-embedded specimens
`were separated from the blocks by soaking in xylene and then
`dried. Five specimens were analysed in dupliC3'te in the fresh
`state and af1er paraffin embedding respeotively; the sitandard
`error of the difference between the means corresponded to a
`coefficient of variation of 7·0%.
`Histological Assessment.-The liver biopsy specimens were
`examined histologically without knowledge of their origins,
`the clinical dcta1b, or the results of chemical analyses. The
`e~tent of hepatic fibrosis was determined on camera lucida
`drawings made from seotions of each biopsy, the area of a
`seotion occupied by fibrous tissue being expressed as a per(cid:173)
`centage of the total area of the section. This has been termed
`the "fibrosis index" (R.isdon et al., 1974).
`
`Results
`The difference in mean liver iron concentration between the
`groups at the start of the trial was not significant ((able).
`Though preliminary biopsies were not performed in all the
`patients this probably did not significantly affect the initial
`comparison. By the end of the trial othe two groups showed no
`overlap in liver iron concentration and ithe difference between
`the respeotive means was highly significant. This was due to
`a pronounced rise (t = 2·15, P < 0·05) in t.he value for the
`controls, that for ~he chclator-treated group showing relatively
`little change.
`
`Comparability of Ch1/ator-t"attd and Control Groups at beginninc and end of
`Trial Ptriod (1966-71 /2). Results Expressed as M1an±S.E. of M1an
`
`Group
`( No. of Patients)
`
`Age
`(Months)
`
`Uniis
`Trans-
`fused
`
`Liver Iron
`No.of
`Concentration Splenec•
`(%dry weight) tomiud
`Patients
`
`1966
`
`Concrob (9)
`
`Significance of
`difference I
`
`Controls (9)
`
`{ Chelator-rreatcd (9)
`1971-2 I Chelator-1reatcd (9)
`
`74 ± 9
`91 ± 11
`
`58 ± 19
`73 ± 11
`
`2·20 ± 0·43•
`3'13 ± 0·411t
`
`P>0-2
`
`P>0·4
`
`P>0-1
`
`I
`:
`
`142 ± 10
`IM ± ll
`
`194 ±33
`223 ± 19
`
`P >0-1
`
`P>0-4
`
`2·59 ± 0·17
`4·22±0-24
`
`P<0-001 I
`
`5
`4
`
`5
`4
`
`Significance of
`difference I
`
`l
`- --
`•Mean of eiaht available biopsy specimens.
`t Mean of seven available biopsy specimen•.
`tr teat.
`
`Relation between Liver Iron ConcentTation and TT<msfused
`Load.-In both the chelator-c:reated and d:ie control patients
`liver iron conccnitration increased with the amount of blood
`transfused but the rise was gmiter in the controls (fig. 1). In
`each group ithe relationship was best expressed . as an ~­
`poncntial funotion of the .transfused load and analysIS of covari(cid:173)
`ance confirmed (hat Jthe respective regression lines were
`significantly non-coincident (t = 4·27, P < 0·001) and
`
`
`2 of 5
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1018
`
`

`

`18
`
`BRITISH MEDICAL JOURNAL
`
`6 APRIL 1974
`
`Controls
`
`J
`
`2
`
`~ .. >
`
`:.::;
`
`0 '--~---,....-~---.-~~..,.....~---..
`0
`200
`400
`JOO
`JOO
`Units of blood tronfwed
`
`FIG. I-Regression line$ ( ::l::S.E. cf e$timate) for liver iron
`concentration on transfused load in chelator-tteated and
`control groups. RegrC$sion equation for chelator-tteated
`patients was y= l·276 logx + 0·109, and for controls
`y=2·572 logx -1·603. Both correlation coefficients were
`significant (P<O·OOI).
`
`different in slope (t = 2·08, P < 0·05). Higher liver iron levels
`transfused load might have been expected in
`relative
`to
`patients who had widergune splencotomy but no such ten(cid:173)
`dency was observed in either group.
`Chewor-treated Patients.-The findings in serial biopsy
`specimens from dle individual patients arc shown in fig. 2.
`The patients fell into two groups. T he first group comprised
`four children with liver iron levels greater than 3 % dry
`weight at .the start of the .trial; two subsequently showed a
`pronowiced fall in liver iron concentration and two main(cid:173)
`tained an approximately constant level. The second group
`comprised five children with initial values of less than 2·4%
`dry weight. In these liver iron concentration showed a highly
`significant exponential rise wi.th increasing .transfused load (r
`= 0·88, P < 0·001) ·to reach a level of 3 % dry weight af1ter
`about 240 units of blood bad been given.
`
`5
`
`4
`
`3
`
`2
`
`~ .. >
`
`.:::;
`
`Control Patients.-Liver iron concentration increased in
`seven patients in whom serial biopsies were performed, and
`fell in one (fig. 3). In one patiem a liver biopsy was not per(cid:173)
`formed until the end of the •trial. The rate of increase in liver
`iron concentration relative to ithe transfused load diminished
`as the values approached 4% dry weight after about 100 Wlits
`of blood had been given.
`
`..-----:;-.
`/
`
`5
`
`2
`
`.2 -E c .. u
`c
`8
`~
`~ .. >
`
`:.:;
`
`0 '--~~---.~~~ ....... ~~~....-~~~
`o
`ro
`200
`JOO
`4CO
`Units of blood transfused
`
`FIG. 3-Liver iron concentration in serial biopsy specimens
`from control patients.
`
`40
`
`JO
`
`:;g
`
`~ .. .. ..., 20
`
`.!:
`
`~
`..0 u::
`
`10
`
`0 .._,.....,~~~.,.-~.....----.-~-.-~..----.~~
`'fli
`'&7
`06&
`'70
`'71
`073
`'bl
`'b8
`'72
`Year
`PIG. 4-ProgrC$sion of hepatic fibrosis in individual control
`patients. Abo shown arc findin1p in two patients in whom
`biopsy had previously been earned out in 1961.
`
`0 --~~__,.~~~...-~~--.~~----.
`0
`100
`200
`400
`Units of blood transfused
`
`FIG. 2-Livcr iron concentration in serial biopsy specimens
`from patients receiving chelation thcrap,Y· O = Pa!ients with
`initial liver iron levels more than 3 Yo dry wciP!t. • =
`Patients with initial values less than 2·4% dry weight.
`
`Histopathological Findings.-At the start of ithc trial the
`fibrosis indices for die cwo groups overlapped widely. The
`mean value for the controls was slightly higher dlan that for
`the chelator-treated patients, dle difference
`just atJtaining
`statistical significance (t = 2·31, 0·025 < P < 0·05). By the end
`of the trial, however, ithere was no overlap in dle values for
`the itwo groups and the difference was highly significant (r =
`
`
`3 of 5
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1018
`
`

`

`BRITISH MEDICAL JOURNAL
`
`6 APRIL 1974
`
`19
`
`~ .. .. ..,
`
`.!:
`
`10
`
`~
`
`~ ...
`
`'bb
`
`'b7
`
`'b8
`
`'bl
`Year
`FIG. 5-ProgtC$Sion of hepatic fibrosis in individual chclator(cid:173)
`trcatcd paticnu.
`
`'tiq
`
`'70
`
`'71
`
`'72
`
`'73
`
`8·28, P < 0·001). This was owing to the occurrence of pro(cid:173)
`gressive fibrosis in the control patients (fig. 4), ·the amoUJllt of
`fibrosis in the chelator-treated group showing no significant
`overall change (fig. 5). At the end of the otrial severe fibrosis
`or cirrhosis (corresponding to fibrosis indices of more than
`25 %) were present in six of the controls but in none of the
`chelator-<treated patiems.
`Clinical Findings.-There were no major clinical differences
`between the •two groups. One patient in the control group su~
`sequcntly died but none died in the chelMor-<rreated group.
`There were small differences favouring the chelator-ueated
`p1tients in height-velocity in prepubertal children (P < 0·?5)
`and
`in height at
`the end of die study
`(not
`sig(cid:173)
`nificant). There was a
`similar
`incidence of diabetes
`mellitus (three and two cases) and of pericarditis with cardiac
`failure (three and four c.ascs) in the chelator-treated and con(cid:173)
`uol groups respectively. One control patient had hypopara(cid:173)
`thyroidism in addition to diabetes mellitus. There was a
`delay of more than two standard deviations in. achieving the
`pubeI'ty ratings (Marshall and Tanner, 1970) m five out of
`nine patients in whom d:ua were available. PubeI'ty was de(cid:173)
`layed in four out of five controls but in only one out d four
`chelator-treated children. A pubenal growth spun occurred
`in the patients with a normal pubeNy but not in those witll
`pubenal delay.
`
`Discussion
`A difficuLty inherem in comparative trial-s in thala-ssaernia is
`that <the patient-s tend ito vary widely ~ many aspeot~ of the
`disease and matched ob'Servations are difficult to obtain. Our
`study was conuolled in that ithe chelator-'tl'Cated. patients were
`compared prospectively with other othalassaenucs who ~ere
`matched as closely a-s possible for sex, age, and tran'Sfus1onal
`status, and were maintained on a similar high tt~sfusi~n
`regimen. The uansfusional requirements of the children is
`one faotor pal'licularly difficult to control. Though the p~t
`children were transfused according to individual need little
`discrepancy developed between the <WO groups during the
`period of study. One advantage of the .high ~sfu~ion regimen
`is that the major endogenous factor influencing iroo absorp(cid:173)
`tion-namely, erythropoiesis---can be assumed Ito have. been
`minimiud so othat iron accumulation can be largely, if not
`completely, attributed to .rhe blood .received. Thw the etfeot
`of chelation therapy on iron stores m the two groups can be
`compared by using the amount-s of blood uansfused as a refer-
`ence.
`. . .:~ ....
`Apan from four chilcken in the chelator:tre~ group wJ1U1
`initially high values, liver iron. concentration mcrcased pro(cid:173)
`gressively in both groups dunng ithe course of the study.
`Nevenheless, the rate of increase relative to the ttan~used
`load was significantly lower in the chelator-;r~ed chil~en
`than in the controls. Though ¢here wa-s no i;ignificant differ(cid:173)
`ence in liver iron concenuation between tthe groups at the be-
`
`ginning of the trial the respective values showed no overlap at
`the end. In ·the chelator-ueated children liver iron concenua(cid:173)
`tion seemed to reach a maximum of about 3 % dry weight
`after 250 units of blood had been given, suggesting that they
`were then in iron balance. In the controls, on the other hand,
`liver iron was continuing (0 rise, albeit at a reduced rate,
`above 4% dry weight at a similar transfused load. The de(cid:173)
`creasing rate of hepatic iron deposition relative <to the amount
`of blood being given in children not 'l"eceiving chelating agents
`may be due to the onset of spontaneous iron cxCl'etion as
`total body iron content becomes massive (Barry and Flynn,
`1974). Berry and Marshall (1967) found that the stainable iron
`in hepatic parenchymal cells was increased in patients with
`thalassaemia who had undergone splenectomy as compared
`with patients who had not. Nevertheless, we found no ten(cid:173)
`dency for total liver iron in children who had undergone
`splenec:tomy in either group to be higher, relative <o the
`transfused load, <than in children who had not.
`The hepatic histological findings showed a clear-cut advan(cid:173)
`tage in favour of the chelator-treated children. With the pro(cid:173)
`longed survival
`that regular itransfusion now confers
`in
`thalassaemia severe fibrosis or cirrhosis is an almost constant
`finding at necropsy (Frumin et al., 1952; Howell and Wyatt,
`1953; Ellis er al., 1955; Wiitzleben and Wyatit, 1955) and the
`progressive fibrosis observed in our control patients conforms
`with this. The lack of progressive fibrosis in the chelator(cid:173)
`treated patients is of pankular interest since most of these
`patients had liver iron concentrations in excess of l ·8 % dry
`weight throughout much or all of the ttial period. This is
`the lower limit of the range generally fowld in untreated idio(cid:173)
`pathic haemochromatosis when it is usually accompanied by
`severe fibrosis or cirrhosis (Barry, 1973). The limited though
`significant reduction in <tissue iron accumulation achieved by
`chelation itherapy would appear to have at least delayed the
`progression of liver injury.
`Pubertal delay is almost invariable in heavily transfused
`patients with thalassaemia and the occurrence of a nonnal
`pubeI'ty in severely affected patients is remarkable. Little
`difference was seen in the incidence of the endocrine and
`cardiac complications in the cwo groups. These are usually
`assumed •to be due <o rna'Ssive iron depo-sition and are expec(cid:173)
`ted only in older patients. Neveritheless, those of our patients
`who arc now in their second decade were already heavily
`loaded with iron when chelation •therapy was started and it is
`not Stuprising that chelation .therapy seem s to have had little
`clinical effect. In younger patients the 'l"everse is <true and it
`may well be that in these •the endocrine and cardiac complica(cid:173)
`tions will be diminished or delayed. Though it is now too
`early to discern any defin~te clinical advantage from chelation
`therapy the greater growth rate in the chelated prepubettal
`children is encouraging.
`In conclusion, !this study has shown mat long-term iron
`chelation therapy significantly i-educes hepatic iron accumu(cid:173)
`lation in patients maintained on a high transfusion regimen
`and thaot .this is accompanied by a significant retardation in
`the progression of hepatic fibrosis. Though the trial wa-s prim(cid:173)
`arily concerned with the management of children with thalas(cid:173)
`saemia the findings are also relevant to the management d
`other iron-loading anaemias. Longer-term srudies are neces(cid:173)
`sary to establish the clinical benefits accruing from this treat(cid:173)
`ment but our preliminary findings are encouraging. The feasi(cid:173)
`bility of using larger doses of desferrioxamine (for
`instance,
`one gramme daily) and the advantages to be gained thereby
`arc funhcr points that merit investigation.
`
`We are gra•cful to the physicians of the Hospital for Sick
`Children for permission to study patients under their care and
`to Professors R. M. Hardisty and Sheila Sherlock for their con(cid:173)
`tinued interest and support. We arc indebted to Dr. E. N.
`Thompson and Dr. Peter de Buse and many other members of the
`staff of the hospital who helped in the management of the patients,
`
`
`4 of 5
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1018
`
`

`

`20
`
`and to Dr. W. C. Marshall who performed all the earlier liver
`biopsies. Dr. J. G. Domcnet of Geigy Pharmaceuticals and Dr.
`D. M. Burley of CIBA generously provided diethylcnctriaminc
`pcnta-acctatc and desferrioxamine respectively.
`
`References
`Barry, M. (1973). Journal of the Royal College of Physicians of Lmulon, 8, 52.
`Barry, M., and t:lynn, D. M . (1974). In preparation.
`Barry, M., and Sherlock, S. (1971). Lancet, 1, 100.
`Berry, C. L., and Marshall, W. C. (1967). Lancet, 1, 1031.
`
`BRITISH MEDICAL JOURNAL
`
`6 APRIL 1974
`
`Ellis, J. T., Schulman, I., and Smith, C. H. (1954). American Journal of
`Pathology, 30, 287.
`Frumin, A. M., Waldman, S., and Morris, P. (1952). Pediatrics, 9, 290.
`Howell, J., and Wyatt, J.P. (1953). Archives of Pathology, SS, 423.
`Marshall, W. A., and Tanner, J. M. (1970). Archives of Disease in Childhood,
`45, 13.
`Risdon, A. R., Barry, M., and Flynn, D. M. (1974). In preparation.
`Smith, R . S. (1962). British MtdicolJournal, 2, 1577.
`Smith, R. S. (1964). Annals of the New York Academy of Science~, 119, 776.
`Whipple, G. H., and Bradford, W. L. (1936). Journal of Pediatrics, 9, 279.
`Witzleben, C. L., and Wyatt, J. P. (1961). Journal of I>athology and Bac-
`teriology, 82, I.
`Wolman, I. J. (1964). Annals of the New York Academy of Sciences, 119, 736.
`Wolman, I. J., and Ortolani, M. (1969). Annals of the New York Academy of
`Sciences, 165, 407.
`
`Fine-needle Aspiration Biopsy of Spleen in Diagnosis of
`Generalized Amyloidosis
`
`A. PASTERNACK
`
`British Medical Journal, 1974, 2, 20-22
`
`Introduction
`
`Summary
`
`Fine-needle aspiration biopsy of the spleen was performed on
`18 patients shown to have amyloid deposits in other organs
`a,ud on 17 control patients being investigated for proteinuria.
`Of the 18 patients with amyloid disease smears of splenic
`aspirate were positive in all cases, renal biopsy was positive
`in 16 out of 16 cases, and rectal biopsy was positive in seven
`out of 11 cases. None of the splenic smears were positive in
`the 17 control patients and no amyloid was found in the kid(cid:173)
`ney in lS ol these patients on whom renal biopsy was per(cid:173)
`formed. Splenic aspirate biopsy seems to be a simple and safe
`procedure for the diagnosis of amyloidosis. It is as accurate as
`renal biopsy and more accurate than rectal biopsy.
`
`Fourth Department of Medicine, University Central Hospital,
`00170 Helsinki 17, Finland
`A. PASTERNACK, M.D., Associate Professor
`
`Generalized amyloidosis is most ofiten diagnosed by percutane(cid:173)
`ous biopsy of the kidney or biopsy of <the rectal mucosa. There
`is a need, .however, for safer but equally reliable procedures
`which are easy to perform on large groups of patients. Thi.s
`paper reporos die resuks of diagnosis by fine-needle asp.i:ra(cid:173)
`tion biopsy of dle spleen.
`
`Patients and Methods
`Fine-needle aspir~on biopsy of. the spleen was performed in
`35 patients. Eighteen had been or were later shown to have
`amyloidosis by biopsy of me kidney, rectum, or other organ
`(itable I). The remaining 17 p~ents (7 women, 10 men), who
`served as conuols were
`in hospital
`for
`the
`investi(cid:173)
`gation of proteinuria (table II). A kidney ·biopsy was per(cid:173)
`formed within one year in all but five of the patients in the
`amyloidosis group. The spleen was aspirated by means of a
`disposable 0·8 x 80 mm needle on a disposable 20-ml syringe
`with Luer adaptor. The 6pleen was located by percussion and
`the needle was usually insetted inro the itenth imercostal space
`about 3-5 cm dorsally ito the mid-axillary line. To avoid dam-
`
`TABLI! 1-Clinical Data and Biopsy Findings in 18 Patients with Generalized Amyloidosis. Median Age 42·5 Years
`
`Case
`No.
`
`Sex
`
`Age
`(Years}
`
`Diagnosis
`
`Amyloid Present in:
`
`Amyloid in Aspirate
`from Spleen
`
`Timing of Biopsies
`
`F.
`
`M.
`M.
`M.
`M.
`M.
`M.
`M.
`M.
`M.
`F.
`M.
`F.
`
`M.
`F.
`M.
`F.
`F.
`
`1
`
`2
`
`3
`4 s
`6
`7
`8
`9
`10
`11
`
`12
`13
`
`14
`15
`16
`17
`
`18
`
`I
`•Medulla.
`tConCJt.
`
`65
`
`37
`
`35
`43
`so
`52
`34
`4-0
`28
`57
`52
`
`46
`17
`
`36
`66
`54
`42
`
`38
`
`Rheumatoid arthritis
`
`Ankylosing spondylitis
`
`,, •
`u
`Hereditary amylo1dosis
`with corneal dystrophy
`Rheumatoid azthritis
`
`..
`..
`..
`
`..
`..
`..
`
`Tu.,;_~c-ulous os'lcitis
`Hereditary amyloidosis
`with corneal dystrophy
`Rheumatoid arthritis
`J uvcnite rheumatoid
`arthritis
`Ankylosing spondylitis
`Bronchiee:w1ae
`
`Skin cu'bcrculosis
`
`Unknown
`
`{
`
`Other Sires
`Gingiva +, liver + ,
`jejunum +
`Gi.nSiva - ,
`Jt1unum +
`Skin -
`Skin +,liver +,
`gast.ric mucosa +
`
`Rectum
`+
`+
`
`Kidney
`
`+
`+
`+
`
`+
`+
`
`-
`-
`+
`+
`
`+
`+
`+
`+
`+
`+
`+
`+
`-
`+
`+
`+
`• } +
`(I) -
`(2} + t
`-
`+
`
`Jejunum -
`
`~
`
`++
`+++
`++
`+++
`+ ++
`
`Diffuse
`Diffuse
`Diffuse
`Diffuse
`
`Peri vascular I
`
`Amount
`
`Localization
`
`+++ ! Diffuse
`I
`
`++
`++
`++ +
`++
`+++
`+++
`+
`+++
`+
`+
`+
`
`Diffuse
`
`Peri vascular
`Diffuse
`I Diffuse
`
`Diffuse
`Diffuse
`Peri vascular
`Diffuse
`Diffuse?
`Diffuse
`
`Pcriva.scular ?
`Diffuse
`
`Within a three-year period
`
`Within a one·yea.r period
`
`During the same period in
`hospital
`
`
`5 of 5
`
`Taro Pharmaceuticals, Ltd.
`Exhibit 1018
`
`